Hospital B Rehabilitation Unit
12. Our geriatrician adviser noted that on admission Mrs D had sinus tachycardia. This is when the heart beats in a regular way and faster than 100 bpm.
13. Often the cause of tachycardia is clear (such as an infection) but sometimes it is not obvious. Doctors will try to look for a cause, especially in more serious causes such as when the patient has chest pain or a high temperature, which were not evident in Mrs D’s case. As tachycardia can be a symptom of thyroid dysfunction, doctors investigated this and found it not to be the cause.
14. Doctors did not investigate it the cause further. Our geriatrician adviser said this was not surprising. Having looked for a cause and done basic investigations of a blood test and electrocardiograph (ECG; a test that records the electrical activity of the heart, including the rate and rhythm) they would be unlikely to investigate further unless the patient was unwell. In this case, Mrs D did not seem to be unwell. The British Heart Foundation website says: ‘If you have sinus tachycardia… it doesn’t mean there's something wrong with your heart and you might not need treatment.’ She was in pain because of her hip; pain can cause rapid heart rate as can anxiety, which would be a natural response to being in hospital with a fractured hip. So there was no indication to investigate the tachycardia further.
15. We consider then that the assessment was done in line with Good Medical Practice, which says:
‘You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must: • adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient • promptly provide or arrange suitable advice, investigations or treatment where necessary’
16. Other than the fractures, there was no indication of anything else wrong. There was no suggestion she had sepsis, which is a life-threatening reaction to an infection. Tachycardia can be benign. It is not always due to a serious illness. Pain and anxiety could be seen a possible cause. Mrs D was otherwise well.
17. Given she was medically stable, the transfer to the rehabilitation unit at Hospital B was appropriate. In other words, she did not need to stay in the acute hospital for further investigations and treatment. The discharge guidance says patients can be discharged home with a NEWS2 score of up to 3. NEWS2 (national early warning score) is a system for scoring measurements, including respiration rate, oxygen saturation, blood pressure, pulse rate, level of consciousness and temperature, in order to help identify patients who are deteriorating. Mrs D’s NEWS2 score was 1 during her stay in the General Infirmary. From a medical point of view, this means it would have been safe to discharge Mrs D home (although there were other reasons which meant she was not ready to return to independent living). So it was safe to transfer her to a rehabilitation unit that was staffed by nurses 24 hours a day and had duty medical staff.
18. With regard to her care at Hospital B itself, our geriatrician adviser said that what happened on 13 August was not predictable. As explained above, although Mrs D had mobility problems, tachycardia and some pain, she was reasonably well. The records from Hospital B show the nursing staff and physiotherapist saw her regularly that they did not have any concerns. Her observations (vital signs) and NEWS2 were done regularly. She had some incontinence, which she did not have before, but this did not point to anything else being wrong at this stage.
19. At 6:18am on 13 August, Mrs D’s NEWS2 score went up to 4. The elevated score was due to her heart rate – which was known about, so it was not a new concern at this stage – but also because her oxygen saturation levels were at 93%. (The amount of oxygen red bloods cells are carrying.) The target was 94 to 98%, so this was only 1% less than the level which would score a zero for this particular measurement. The NEWS2 guidance from the RCP, says that a medical review is required with a score of 5 or above. So, the trigger for her to be seen by a doctor was not met at that time. It was not an indication of at risk of serious deterioration. After some deep breathing exercises, Mrs D’s oxygen levels went up to 94% and her heart rate reduced. Her NEWS score came down to 2.
20. A healthcare assistant helped Mrs D have a shower. Shortly after, at 11.13am, Mrs D’s NEWS2 went up to 5, with a higher respiratory rate and heart rate, and increased pain, although her oxygen levels were still within range. A score of 5 requires a number of interventions to take place including an assessment by a doctor.
21. Our geriatrician adviser says that Mrs D’s deterioration was rapid and when it happened, she was well managed and in line with the Royal College of Physicians guidance; nursing staff got a doctor to review her quickly. The doctor advised nurses to do an ECG and to give Mrs D oxygen therapy. Sadly, Mrs D continued to deteriorate and by 12:05pm, her NEWS2 score had gone up to 10.
22. After speaking to a consultant in the Emergency Department, the doctor decided to transfer Mrs D back to an acute hospital (this time it was Hospital C) by emergency ambulance. There is no indication of a missed opportunity to have acted more quickly in that regard. The records show Mrs D was still saying she was feeling quite well shortly before her deterioration.
23. It turned out Mrs D had e-coli septicaemia. This is a serious condition that happens when E. coli bacteria enter the bloodstream and spread through the body. Our geriatrician adviser explained this is most commonly from a urinary tract infection (UTI). Symptoms can be subtle early on. Once infection enters blood stream, the patient can deteriorate dramatically as in Mrs D’s case. Furthermore, the coroner found Mrs D to have had significant cardiac problems, with narrowed arteries and heart valves. These had not been diagnosed when she was alive. In hindsight, the sudden and rapid deterioration is not unexpected, but it would have been unexpected at the time because there was no sign or reason to believe it was going to happen.
24. We have seen no indication of any failures in the Trust’s care and treatment of Mrs D while she was in Hospital B.
25. Miss B also said her mother should have been given more help to use the toilet or use a catheter rather than being left with incontinence pads. There were two new problems in this regard; Mrs D experienced new incontinence and her mobility was limited because of her injuries and she could not get to the toilet independently. Our nursing adviser explains that nursing staff needed to consider her privacy and dignity. The records show that staff helped her to get to the toilet or brought her a bed pan when she was aware she needed to go. The pads would help if this was not possible and would have helped to avoid having to change bedding more often. This was in line with the NMC Code, which says that nurses should ‘Treat people as individuals and uphold their dignity’.
26. In its response the Trust explained that a catheter was not indicated. Our nursing adviser says this is reasonable. A catheter is avoided when possible because it is invasive and has a risk of infection.
Hospital C Emergency Department
27. Mrs D arrived at the Emergency Department at 1:25pm and the ambulance crew handed over her care immediately. Emergency Department staff recognising her NEWS2 score of 10, took her to the resus area. Our emergency medicine adviser explains that when someone comes in to the Emergency Department and is critically unwell requiring immediate one-to-one care, they are taken to the resus area. It provides the highest level of care in the Emergency Department. She was assessed by a doctor within a few minutes. Therefore, we have seen she was triaged within the requirements of the Royal College of Emergency Medicine guidance.
28. A NEWS2 score of 7 and above requires continuous monitoring of vital signs and escalation, in line with the Royal College of Physicians guidance and this is what happens in resus.
29. Mrs D Was reviewed by a geriatrician consultant at 6:08 PM. She noted Mrs D was critically unwell. Blood test results show Mrs D had a lower respiratory tract infection. The geriatrician suspected she this may be due to a problem in her abdomen. She was given Tazocin, which is an antibiotic used to treat a number of infections.
30. Our emergency medicine adviser says the diagnosis of a lower respiratory tract infection was reasonable considering Mrs D’s symptoms. The intensive care team and surgical team were contacted for their input. Because of Mrs D’s increased respiratory rate, doctors wanted to do a CT scan of her chest to investigate the possible lower respiratory tract infection or a pulmonary embolus (a blood clot in the lung).
31. Unfortunately, she was too ill to have the scan and Mrs D went into cardiac arrest at around 5:48pm. There was an attempt to resuscitate her, which initially was able to restart her heart. However, she remained critically ill. A doctor explained to family members that he was concerned that her heart would stop again in the next few minutes and that if it did, they would not try again to resuscitate her. Mrs D died soon after. Our emergency medicine adviser set that the resuscitation attempt was appropriate, and it included the consideration of whether there was a cause of the cardiac arrest that they could treated. Sadly, it was unsuccessful.
32. Overall, we consider that Mrs D was investigated and treated in line with Good Medical Practice, which says:
You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must:
• adequately assess the patient’s conditions, taking account of their history, including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient • promptly provide or arrange suitable advice, investigations or treatment where necessary • refer a patient to another practitioner when this serves the patient’s needs.
33. We consider Mrs D was managed appropriately in the emergency department. We have seen no reason to believe her sad death could have been prevented.